Cardholder Storage Compliance & Service Provider

***** Payment Card Industry Data Security Standards ("PCI DSS") and card association rules prohibit storage of track data under any circumstances. If you or your Point of Sale ("POS") system pass, transmit, store or receive full cardholder's data, then the POS software must be Payment Application Data Security Standard ("PCI DSS") compliant or you (merchant) must validate PCI DSS compliance (see 31(b) below and questions #3 and #4 must be completed). If you use a payment gateway, they must be PCI DSS compliant. *****

Have you ever experienced an Account Data Compromise("ADC")?*

YesNo

If yes, provide date of compromise (MM/dd/yyyy)

Have you validated PCI DSS compliance?*

YesNo

If yes, go to #1(c); If no, go to #2

If yes, give the Date:

Self-Asssessment Questionnaire (SAQ):

Qualified Security Assessor (QSA):

Approved Scanning Vendor (ASV):

Date of last scan (MM/dd/yyyy)

Do you or your Third Party Provider(s) receive, transmit, or store Full Cardholder Data Electronically?*

YesNo

Payment Application or Software

Model or Version Number:

Third-Party Provider:

Is this provider PCI DSS Compliant?

YesNo

Virtual Terminal or Payment Gateway:

Access to Cardholder Data?

YesNo

Web Hosting Vendor:

Access to Cardholder Data?

YesNo

Shopping Cart Vendor:

Access to Cardholder Data?

YesNo

Other Service Provider:

Access to Cardholder Data?

YesNo

Owner(s) or Officer(s)

(Individual ownership must be greater than or equal to 50%)

#1 - Owner or officer

Name

Title

Date of Birth (MM/dd/yyyy)

Social Security #

% Equity Ownership

Residence Address

City

State

Zip Code

# of years lived at current residence

Home Phone #

Drivers License #

Drivers License State Issued

#2 - Owner or officer

Name

Title

Date of Birth (MM/dd/yyyy)

Social Security #

% Equity Ownership

Residence Address

City

State

Zip Code

# of years lived at current residence

Home Phone #

Drivers License #

Drivers License State Issued

Rate Schedule

By checking this box you agree that you have read, understand, and accept the Rate Schedule as outlined here Merchant Rate Schedule

Debit/Credit Authorization

Merchant authorizes any part to the Agreement to present Automated Clearing House credits, Automated Clearing House debits, wire transfers, or depository transfer checks to and from the following account and to and from any other account for which any such parties are authorized to perform such functions under the Merchant Processing Agreement, for the purposes set forth in the Merchant Processing Agreement. This authorization extends to such entries in said account concerning lease, rental or purchase agreements for POS terminals and/or accompanying equipment and/or check guarantee fees and amounts due for supplies and materials. This Automated Clearing House authorization cannot be revoked until all Merchant obligations under this Agreement are satisfied, and Merchant gives written notice of revocation as required by this Agreement.

INVESTIGATIVE CONSUMER REPORT: An investigative or consumer report may be made in connection with application. MERCHANT authorizes ANY PARTY TO THE AGREEMENT or any of their agents to investigate the references provided or any other statements or data obtained from MERCHANT, and from any of the undersigned personal guarantor(s), or from any other person or entity with any financial obligations under this Agreement. You have a right, upon written request, to a complete and accurate disclosure of the nature and scope of the investigation requested.

BANK CARD

Average Ticket Size*

Highest Ticket Size*

Monthly Volume*

AMEX

Average Ticket Size*

Highest Ticket Size*

Monthly Volume*

By checking this box, Merchant opts out of receiving future commercial marketing communications from American Express. Note that you may continue to receive marketing communications while American Express updates its records to reflect your choice. Opting out of commercial marketing communications will not preclude you from receiving important transactional or relationship messages from American Express.
I Opt Out

Equipment / Additional Services

Which of the following would you like to take?

Would you like to apply to take American Express?*

YesNo

If you are an existing merchant who has an existing American Express Merchant ID#, please provide it here

Merchant Refund Policy

EBT

Debit

Gift

Loyalty

Voyager

FleetCards

NFC / CTLS (Apple Pay)

Cash Only

Supermarket (Addendum Required)

PRN

EVO Check

Other

Mail Account Statments to me at

Each person certifies that the average ticket size and sales volume indicated is accurate and agrees that any transaction or monthly volume that exceeds either of the above amounts could result in delayed and/or witheld settlement of funds. Also see paragraphs 4.C, 9 and 13.B of the MERCHANT Processing Agreement regarding suspension and termination of MERCHANT. *Highest ticket for informational purposes only.

IMPORTANT NOTICE: All information contained in this application was completed or supplied by all contracting parties. Evo and BANK shall not be responsible for any change in printed terms unless specifically agreed to in writing by an officer of Evo and BANK. By signing on either the original or a facsimile you are agreeing to the provisions stated within the Terms and Conditions of the Merchant Processing Agreement and the Merchant Application on the reverse side, and you are acknowledging that you have carefully read each of those provisions before signing.

FOR ALL CORPORATIONS CORP. RESOLUTION - The indicated officer(s) identified in numbers 1 and/or 2 below have the authorization to execute the MERCHANT Processing Agreement on behalf on the herewithin named corporation. MERCHANT UNDERSTANDS THAT THIS AGREEMENT SHALL NOT TAKE EFFECT UNTIL MERCHANT HAS BEEN APPROVED BY BANK AND A MERCHANT NUMBER IS ISSUED.

Personal Guaranty (No titles)

As a primary inducement to Evo and Bank to enter into this Agreement, the undersigned Guarantor(s), by signing this Agreement, jointly and severally, unconditionally and irrevocably, personally guarantee the continuing full and faithful performance and payment by Merchant of each of its duties and obligations to Evo and Bank under this Agreement or any other agreement currently in effect or in the future entered into between Merchant or its principals and Evo and Bank, as such agreements not exist or are amended from time to time, with or without notice. Guarantor(s) understands further that Evo and Bank may proceed directly against Guarantor(s) without first exhausting their remedies against any other person or entity responsible to it or any security held by Evo and Bank or Merchant. Guarantor(s) waive trail by jury with respect to any litigation arising out of or relating to this personal guaranty. This guaranty will not be discharged or affected by the death of the undersigned, will bind all heirs, administrators, representatives and assigns and may be enforced by or for the benefit or any successor of Evo and Bank. Guarantor(s) understand that the inducement to Evo and Bank to enter into this agreement is consideration for the guaranty, and that this guaranty remains in full force and effect even if the Guarantor(s) receive no additional benefit from the guaranty.
AGREED AND ACCEPTED

FOR ALL CORPORATIONS CORP. RESOLUTION -- The indicated officer(s) identified in numbers 1 and/or 2 below have the authorization to execute the MERCHANT Processing Agreement on behalf of the herewithin named corporation. MERCHANT UNDERSTANDS THAT THIS AGREEMENT SHALL NOT TAKE EFFECT UNTIL MERCHANT HAS BEEN APPROVED BY BANK AND A MERCHANT NUMBER IS ISSUED.

If Merchant submits a transaction hereunder, Merchant will be deemed to have accepted the Terms and Conditions of the Merchant Processing Agreement.For Merchants who have elected to accept the American Express Card, the submission of an American Express Card transaction will be deemed to be an acceptance of the American Express Card Acceptance Agreement and the above American Express provisions (located within the Merchant Rate Schedule).

By checking this box you agree that you have read, understand, and accept the Merchant Processing Agreement as outlined here Merchant Processing Agreement